Operationalizing Psychological Flexibility

Psychological flexibility has widely been measured by the Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004) in adults. The AAQ is a self-report measure that assesses the two aspects of those low in PF, namely experiential avoidance and cognitive fusion. Respondents are asked to rate the degree to which they feel entangled with their difficult

thoughts, the extent to which private experiences are negatively evaluated, the extent to which they avoid, escape or control their emotions and the extent to which in the presence of difficult thoughts and feelings, they are unable to act effectively. The 9 and 16 item versions were developed to capture the PF phenomena as a unidimensional construct, and reliability and validity studies on all versions predominantly point to a single latent factor (Hayes et al., 2004). The AAQ has been used in a wide array of studies. In a meta-analytic study, the AAQ was shown to predict a wide range of psychopathological and well-being measures, including depression, anxiety, general mental health, quality of life, job satisfaction, future absenteeism, and future performance on the job (Hayes et al., 2006).

Although the AAQ demonstrated good reliability and criterion-related, convergent, predictive, and discriminative validities at the time of development, there has been a problem with the internal consistency of the AAQ in subsequent studies (Bond et al., 2011). Low alphas were observed particularly in community samples and subpopulations with low education and amongst those with English as a second language. Revisions to address the weaknesses of the AAQ, led to the development of the AAQ-II (Bond et al., 2011). In addition to the AAQ-II, several variants of the AAQ for particular problems were also developed. Some of the problems for which the AAQ measure has been modified include smoking (Farris, Zvolensky, DiBello, & Schmidt, 2015), substance abuse (Luoma, Drake, Kohlenberg, & Hayes, 2011), body image (Sandoz, Wilson, Merwin, & Kate Kellum, 2013), weight (Lillis & Hayes, 2008), auditory hallucinations (Shawyer et al., 2007), chronic pain (McCracken, Vowles, & Eccleston, 2004), tinnitus (Westin, Hayes, & Andersson, 2008) and diabetes (Gregg, Callaghan, Hayes, & Glenn- Lawson, 2007). In the disorder specific versions, the more general terms pertaining to thoughts, feelings, and actions in the items have been replaced with more domain specific terms of the clinical problems. Similarly, an entirely new measure of PF, the Action and Fusion

Questionnaire for Youth (AFQ-Y; Greco, Lambert, & Baer, 2008), was developed specifically for children and adolescents.

Similar to the AAQ, the AFQ-Y also assesses experiential avoidance and cognitive fusion and high scores on the AFQ-Y are indicative of psychological inflexibility and low scores psychological flexibility. The AFQ-Y is a self-report measure with a short version consisting of 8 items and a long version consisting of 17 items (Greco et al., 2008). The internal consistency reliability for the AFQ-Y has been high in youth populations with reported alphas ranging from .81 to .93 (Fergus et al., 2012; Greco et al., 2008; Howe-Martin et al., 2012; Schmalz &

Murrell, 2010). The intended purpose of the AFQ-Y was to assess PF in children at least 10 years of age and also to enhance comprehension through the reduced use of ACT specific language in the items. The items use simple language to facilitate more valid responding among young people. Content-wise, the items in the AFQ-Y represent general response behaviours

although items are specific to setting events, reminiscent of the domain specific AAQ measures. A sample question would be “I do worse in school when I have thoughts that make me feel sad.”

Although the AFQ-Y was developed for children and adolescents, the AFQ-Y should ideally show a meaningful association with existing measures of PF and be comparable in relation to measures of psychopathology and well-being. To examine the relationship between the AFQ-Y and AAQ-II, two different samples of adults were assessed (Fergus et al., 2012). In the first sample consisting of college students, the reading level and factor structure for the using the AFQ-Y was assessed. In the second sample, 115 patients with multiple diagnoses from an intensive anxiety outpatient program completed several clinical measures in addition to the AFQ-Y and AAQ-II which included the Anxiety Sensitivity Index-3 (Taylor et al., 2007), Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the Social Interaction Anxiety Scale (SIAS; Mattick & Clarke, 1998), the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988), the Panic and Agoraphobia Scale (PAS; Bandelow, 1999), and the Dimensional Obsessive-Compulsive Scale (DOCS; Abramowitz et al., 2010).

In both samples, the factor structure of the AFQ-Y yielded a one-factor model, confirming its construct validity. A high value for the Cronbach’s alpha statistic (α = .93) indicated excellent internal consistency in the sample involving college students. In the clinical population, internal consistency for the AFQ-Y was reported as α = .90 and for the AAQ-II α = .89. The correlations between the AFQ-Y and AAQ-II in the second sample was r = .70. The convergent correlations between the two PF measures were considered high enough to

demonstrate that the same underlying construct was being measured; however, this was further tested by incremental concurrent validity tests. The AFQ-Y incrementally predicted the scores of all psychological symptoms above and beyond the AAQ-II except for the obsessive

compulsive measure (Fergus et al., 2012). However, the AAQ-II did not predict any unique variance for all psychological symptoms except for the obsessive compulsive measure.

In another study comparing the AFQ-Y and AAQ-II in adults, a college sample

completed the AFQ-Y, the AAQ-II, the Symptom Checklist-90-R (SCL-90-R; Derogatis, 1994), the Depression Anxiety Stress Scale (DASS; Lovibond & Lovibond, 1995), the Kentucky Inventory of Mindfulness Skills (KIMS; Baer, Smith, & Allen, 2004) and the Quality of Life Inventory (QOLI; Frisch, 1994) (Schmalz & Murrell, 2010). The factor structure of the AFQ-Y also yielded a one-factor model and the Cronbach’s alpha was similar to the above sample of college students (α = .92). In this study, the AFQ-Y did not predict unique variance for the quality of life measure above and beyond the AAQ-II (Schmalz & Murrell, 2010).

In conclusion, the AFQ-Y was found to be applicable for all ages starting from the fifth or sixth grade comprehension levels (Greco et al., 2008) and was comparable with the AAQ -II in terms of the underlying construct, in measuring symptom-based psychological constructs (Fergus et al., 2012), and in measuring well-being in terms of quality of life (Schmalz & Murrell, 2010). Moreover, the AFQ-Y was inversely related to measures of psychological symptoms and directly related to measures of well-being (Greco et al., 2008).